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viernes, 6 de mayo de 2016

AF: management pearls in the ED

AF and AFL with RVR are common ED diagnoses that require prompt evaluation and treatment as uncontrolled AF and AFL may ultimately lead to stroke, heart failure, and premature death. Emergency physicians are not only in the unique position to make the initial diagnosis, but also provide patients with treatments that may prevent stroke, heart failure and death.

Emergency providers should initially assess stability and evaluate and treat any reversible causes such as sepsis or hyperthyroidism. Workup for ACS may or may not be necessary and should be considered on a case by case basis. If eligible, unstable patients should be cardioverted and anticoagulated as per protocols mentioned above. There have been no clear studies demonstrating long-term differences between rate and rhythm control in stable patients and thus, emergency providers can consider either option. However, stroke risk should always be kept in mind with both the rate and rhythm approaches and the AHA/ACC, EHC or Canadian guidelines should be referred to when determining anticoagulation needs. Patients with preserved LV function should be rate controlled to at least < 110 bpm or < 100 bpm in all others. Data on beta blockers versus calcium channel blockers remains limited and therefore, either medication may be chosen based on a case by case basis. Currently, there is no validated data on patients who may be discharged home versus admitted, but certain patients may be candidates for discharge if they are hemodynamically stable and have no comorbid conditions. Clinicians should continue to use clinical judgement regarding disposition.

In conclusion, while the research on the management of AF and AFL is quite extensive, there are areas that still require further study, such as managing rate versus rhythm, anticoagulation needs, and disposition decisions. Future studies will need to be conducted, but in the meantime, the most recent society guidelines provide useful recommendations on the management of these difficult patients."